A 78 year old male is noted to have a haemoglobin of 89g/L with an MCV of 108fL. His neutrophil count is low at 0.9 x 109/L and platelets are found to be 79,000. He feels tired and has no past medical history outside of hypertension, for which he is on hydrochlorothiazide.
Provide an approach for investigating his pancytopenia.
Points of discussion:
- DECREASED PRODUCTION:
- Aplasia
- Congenital (typically identified pre young adult)
- Acquired
- Medications (i.e. chemotherapy) or radiotherapy
- Lymphoproliferative disorders (T-LGL, HCL)
- Infections (HIV, hepatitis)
- Toxins (Alcohol)
- Overwhelming infection
- Anorexia Nervosa
- Aplastic Anemia
- Paroxysmal Nocturnal Hemoglobinuria
- Hematologic malignancy: MDS, AML, myleoma etc (typically see a hypercellular marrow)
- Marrow replacement (i.e. granulomatous disease, any cancer)
- B12 or RBC folate deficiency (typically see a hypercellular bone marrow)
- Aplasia
- INCREASED DESTRUCTION
- typically due to autoimmune destruction
- HYPERSPLENISM
Points for discussion include the investigative work up for undifferentiated pancytopenia:
- CBC
- Peripheral blood film
- Reticulocyte count
- B12
- Red blood cell folate
- HIV
- Hep B/C
- ANA (additional connective screen as per history and clinical exam)
- SPEP
- +/- Screen for paroxysmal nocturnal hemoglobinuria (in context of positive hemolytic parameters such as elevated LDH or undetectable haptoglobin)
- Abdominal ultrasound
- Medication and toxin exposure history
- Bone marrow biopsy
